James Fowler does it again. He has just published another terrific and useful paper, "Core principles in treating suicidal patients." This makes a terrific companion piece to his previous paper describing "guidelines for imperfect assessments" which I have raved about and recommend all the time. The current paper is elegant and straightforward. Dr. Fowler provides a rationale, evidence, and a treatment example for three core principles:

alliance building

enhancing curiosity about the function of suicidal thoughts and urge

enhancing experience and epxression of intense emotions

Voila! What more do you want? You have to put Dr. Fowler's name on your search engine alert list! I just added it to the reference list that I will distribute at my next Commitment to Living workshop.

The New York Times published an article this week that readers of this blog should be aware of. The article is titled, Study Questions Effectiveness of Therapy for Suicidal Teenagers. The article reports on results from a study published in JAMA Psychiatry (the new name for Archives of General Psychiatry) by Matthew Nock and a team of outstanding scientists. The NYT headline is based mostly on the finding that:

...suicidal adolescents typically enter treatment before rather than after the onset of suicidal behaviors. This means that mental health professionals are not simply meeting with adolescents in response to their suicidal thoughts or behaviors, but that adolescents who are clinically severe enough to become suicidal more typically enter treatment before the onset of suicidal behaviors. There is no way to know from the NCS-A data how often this early intervention prevents the occurrence of suicidal behaviors that would otherwise have occurred but were not observed in our data. It is clear, though, that treatment does not always succeed in this way because the adolescents in the NCS-A who received treatment prior to their first attempt went on to make an attempt anyway. This finding is consistent with recent data highlighting the difficulty of reducing suicidal thoughts and behaviors among adolescents. (Nock et al, (2013) Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents, JAMA Psychiatry, ePub ahead of print, p. E9)

The Nock article is hefty and I have not yet fully digested it. So I will withhold judgement about the article's conclusions, and about whether the NYT article reported them fairly and accurately. However, I am pleased about the discussions that this study and the Times article have the potential to stimulate. One conversation is about how to improve the quality and effectiveness of treatment for at-risk adolescents. This is not a new conversation, but continues to be an important one. Another conversation I hope this NYT article will stimulate relates to broadening our view of what suicide prevention is. With some important exceptions (including some here in New York State), the dominant strategy in suicide prevention has been to identify youth who are suicidal and get them into treatment. As my mentor, Peter Wyman has demonstrated (Wyman et al, 2008) and this Nock article brings to the surface, these 'identify and refer' strategies are limited by a number of factors, including availability and acceptability of services, the length of time adolescents remain in services, the effectiveness of therapy, and adolescents' tendency not to disclose suicide concerns to adults (Pisani et al 2012). While I am committed as ever to improving the quality of screening, assessment, and treatment for at-risk adolescents (and help to train hundreds of clinicians each year), I do not expect that treatment services alone will be sufficient for reducing suicide in the population. For this reason, in my research I am pursuing youth suicide prevention strategies aimed at addressing risk and protective processes further "upstream" (a term I learned from Dr. Wyman). In an article soon to be published, I argue that we need new interventions that can flexibly reach a broader population of adolescents further upstream and that these will require making use of new delivery systems, designs, and technologies.

I look forward to studying the Nock article and to participating a discussion that could help stimulate the field to re-examine what "prevention" really means. Substance abuse prevention does not start with finding kids who are already taking drugs. Fire prevention doesn't start with the fire department. We need great fire departments and well-trained fire fighters, but fire protection engineering and public education make major conflagrations rare. Likewise, youth suicide prevention must focus more broadly then on adolescents who are already suicidal.

Over the past few years, many mental health care systems have adopted useful strategies and technologies to reduce risk across their systems. In my consultations with health systems, I have seen enormous advances in terms of consistent nomenclature, universal screening, documentation standards, assessment procedures, and crisis response planning. A lot of interest has coalesced around certain helpful tools such as the Columbia Suicide Severity Rating Scale and Safety Planning, which help with key tasks that are part of the overall competent care of suicidal patients.

Competent implementation of suicide prevention technologies in clinical care depends on the attitudes and approach with which the professional applies them. Even as we make progress on systematic care for suicidal individuals, have we invested enough attention to fostering the attitudes and approaches that undergird effective care for suicidal individuals and their families? Evidence-based assessment and response to suicide risk includes forming cordial and collaborative relationships, conveying human compassion, building on natural strengths and supports, and promoting dignity and hope. Many major therapeutic interventions for suicidal individuals share common foundations in this regard--DBT and CAMS are good examples--and most clinicians are highly capable of forming bonds of caring with their patients and their families. However, the well-documented challenges (uncertainty, powerlessness, time burden, anxiety) of clinical work with suicidal individuals can interfere with authentic expressions of empathy, commitment, and respect, potentially reducing the yield from other measures taken to assess and reduce suicide risk, such as well-timed screening and safety planning. These challenges also tend to narrow clinicians’ focus on the patient alone, sometimes to the exclusion of interested family and friends. As a result, continuing professional education is needed to empower clinicians with a conceptual framework for understanding and responding to suicide risk that will promote desirable attitudes and behavior across treatment modalities, prevention technologies, and episodes of care.

Patient and family centered care (PFCC) provides a useful framework for developing attitudes and behaviors consistent with best-practices in the compassionate care of suicidal patients. PFCC is a movement that is re-centering healthcare on the experience of the patient and family as a key factor in health care quality and safety. PFCC encourages envisioning all aspects of a health-care system from the patient's perspective, from policies and facility lay-out down to specifics of the clinical encounter. PFCC is a major focus across my home institution, with expertise coming from the Institute for the Family with which I am affiliated. I am not aware of any broad application of this term to the care of patients who present with suicide risk, but I have recently been thinking about CTL in these terms. I have been trying to boil down the PFCC approach I teach in CTL. This remains a work in progress. So far, I have generated these six hallmarks of patient and family-centered response to suicide risk:

Elicit the experience and function of suicidal thinking from the perspective of the person at risk and their family members.

Convey empathy for suffering, a desire to help relieve it, and confidence that recovery is possible.

Invite individuals and their families to make decisions about addressing suicide risk based on their ideas, expectations, and preferences, providing informed consent about risks and benefits of various options.

Explore how plans and decisions for responding to suicide risk will affect and be affected by the person's family, social network, interests, and responsibilities.

Express personal and institutional commitment to alleviating current distress and supporting the life and happiness of the person and their family members.

These clinical principles are not unique or original to CTL. The SPRC/AAS Core Competencies (pdf) include these skills from a different vantage point and vernacular. There are also a host of constituent skills and attitudes that are part of specific treatment modalities. Nevertheless, I have seen a clear need for a direct and transtheoretical focus on these core points.

Because these five points are at the heart of CTL education and consultation, I have been considering re-wording the subtitle of the CTL workshop, and of this blog. For some time, the tagline for CTL has been "Understanding and Responding to Suicide Risk." I settled on that broad moniker at the advice of colleagues who thought the original title was too cumbersome: "Assessment and Decision-making for Competent and Caring Clinicians." They were right; however, as my thinking has evolved and my assessment of needs in the field has sharpened, I may want CTL to reflect the patient-centered focus more directly, perhaps with the title, “Commitment to Living: Patient and Family-Centered Response to Suicide Risk.”

Whatever the title of CTL, the time has certainly come to incorporate the helpful and empowering concepts from the PFCC movement into the way we work with individuals at risk for suicide.

Thanks to Susan H McDaniel, PhD, Dr. Laurie Sands Distinguished Prof. of Families & Health at the University of Rochester Institute for the Family, for her input on this article.

I love the title of J. Christopher Fowler's article that was published in the current issue (vol 49, issue 1) of Psychotherapy, "Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments." This practice review is thorough and wise. Fowler strikes just the balance between encouraging completeness and responsibility, and acknowledging the limits inherent in assessments of risk. Dr. Fowler also masterfully weaves in the importance of self-awareness on the part of the clinician, and gives constant attention to maintaining a caring, compassionate stance. Some selected quotations to whet your appetite for this article:

"Knowing that patients frequently deny suicidal thoughts before suicide attempt and death, clinicians should remain appropriately circumspect regarding declarations of safety when a patient recently expressed suicidal ideation, feelings of hopeless, desperation, and/or affective flooding. This does not mean we should adopt a suspicious or adversarial stance—on the contrary, curiosity, concern, and calm acceptance of the patient’s emotional and cognitive states may serve to enhance the therapeu- tic alliance, encourage the patient to directly explore her or his current distress, and aid in the accurate evaluation of current functioning."

"Before conducting a formal suicide assessment, clinicians should conduct an introspective review of recent stressful life events facing the patient, including recent ruptures in the thera- peutic alliance, and disturbances in social relationships (Truscott, Evans, & Knish, 1999). Maintaining a therapeutic stance of curiosity and concern (while simultaneously remaining open to the possibility that an alliance rupture may be a precipitant to the crisis) is difficult to sustain when anxieties are running high; however, communicating genuine curiosity and concern about the causes for their unbearable suffering is critical."

"When clinicians face a potential suicide crisis, they are multi- tasking and are usually in a state of heightened alert and anxiety. Under such stressful circumstances, it is easy to get swept up in personal emotional reactions and lose sight of the patient’s suffering and their efforts to communicate distress."

My only critique involves the absence of family system context. I would have liked to see some attention to the positive role that family members can play in the assessment process. The article does mention that the quality of family relationships is an important modifiable risk factor, which should be considered and may be the focus of clinical intervention. But most of the article, and the clinical approach advocated, has a decidedly individualistic bent. The article doesn't address how to involve friends and family members in the interview process, how to build their participation into the decision-making process, how the relational context influences decisions about how to respond to identified risk. For me this is an important gap, and a contribution that is still needed.

This gap notwithstanding, this article will instantly join the Bryan et al. means restriction article on my Top 10 Most-recommended List. In fact, the Fowler article could become my primary go-to reference when clinicians ask for reading on the subject.

I am a huge fan of Craig Bryan. He, Sharon Stone, and David Rudd (another person whose work I really admire) have just published an article titled, "A Practical, Evidence-Based Approach for Means-Restriction Counseling With Suicidal Patients." I know I will be recommending this article a lot. Questions about means restriction come up just about every time I teach or consult with mental health professionals about managing suicide risk. This will be my go-to resource from now on. The authors carefully present the evidence for means restriction, and provide a clear and immediately useful guide for conducting means restriction counseling. Highly recommended:

A practical, evidence-based approach for means-restriction counseling with suicidal patients.

A colleague pointed me to a Washington Post article describing an interactive suicide prevention video the Army has produced and will make mandatory for all soldiers. I experimented with the online demo of Beyond the Front, which shows scenes from the life two soldiers and allows the viewer to make choices that either lead toward or away from help and survival. The demo portion I reviewed focuses on the decision a distressed soldier faces in deciding to talk with the chaplain or not. I was impressed with the quality of the video and interested by the approach.

I am not expert enough in public awareness and mass media approaches to prevention to comment or speculate about how effective this video might be in preventing suicide in the Army. But I would like to comment on some intersections between the approach this video takes and some ideas about clinical practice.

To me, one of the most powerful aspects of this video is the way in which it leads the soldier-viewer to see him/herself as potentially at risk for suicide. The video gives the message "If you don't get help, your life could be in danger." Since the video is interactive, the viewer can actually make decisions (like keeping the distress or suicidal thoughts secret) that eventually lead to death.

From a clinical perspective, I have found that putting in front of a person--sometimes in a dramatic way--the danger he or she is in can actually help to kick in the person's survival instinct. It sounds strange to warn someone of danger when the danger is from oneself. But a question like this one can be sobering: "If there were nothing we could do to move life be more livable, how likely would you be to die?" I worked with someone who could not name a single reason why life could have worth or meaning and who could identify no chance for things to get better, but who, when asked that question, started talking about his son and two other people he wouldn't want to leave behind. Recently, I was pleased to hear a similar question encouraged in the ASIST approach to suicide prevention and intervention. An advanced variation of this question might even embed the prospect of hope within the danger question: "If there were nothing we could to help life be more livable--I think there are things, but let's say we didn't pursue them--If things continue like this, how likely would you be to die?"

It is strange and surprising to some clinicans that most people who are suicidal (and I would venture to say some who actually kill themselves) don't want to die. Many people who have survived near lethal suicide attempts have reported that. A participant in a workshop I gave several months ago illustrated this for me in a compelling way. This participant had, at an earlier point in her life, attempted suicide. She had since recovered and pursued education in the mental health field. In sharing her subjective experience of the suicidal wish, she said, "I never wanted to kill myself. I just wanted to kill the pain." What a gift. Clinicians should be aware of this and look for ways to simultaneously connect with the suffering and activate the part of every person that desires life.

I've had a nice response to the brief commentary I posted in conjunction with a link to the NY Times article about means restriction. In light of that, I thought I'd post a link to the a site called Means Matter, which is published by the Harvard Injury Control Research Center. The site has summary pages called "Taking Action" for families, communities, and clinicians.

The talking action page for clinicians is worth reading for any clinician, and could be especially useful to primary care providers. I'm thinking a lot about primary care right now because (a) primary care psychology has beeen a focus of my career and I have a deep respect for the breadth of responsibility primary care providers carry, including in suicide prevention (b) I'm still pondering the recent question I considered about self-trasport and (c) I'm presenting a talk titled "Tips for Suicide Risk Assessment and Response in Primary Care" next month at the Highland Family Medicine center here in Rochester.

I havementionedquiteafew NY Times articles in this blog because I think they cover suicide really well. Last month they published a piece in the NY Times Magazine that I keep recommending to people in informal and clinical discussions, so I thought I'd link to it here. Many thanks to my colleague Bill Watson for first alerting me to the article.

The Urge To End It, by Scott Anderson, is a stunning piece. Well-written, and well-researched, it challenges the stereotype that suicide is always well thought out, carefully planned, and the result of a conscious and un-ambivalent decision. He focuses on the impulsivity and momentary desperation involved in many suicide attempts, and raises awareness about means restriction as a potent intervention.

For clinicians, there are several important take-home points and cautions:

Expressed suicidal ideation is only one part of an assessment of risk for suicide; impulsivity, high intensity stressors, and agitated emotional pain signal as much about risk as suicidal ideation.

We need to ask about available means and seek to disable lethal means whenever possible.

We need to advocate for public policy that promotes means restriction--this may save the life of someone in our care (or in our lives).

Ambivelance runs deep. Even in the moment of jumping, survivors report feeling regret, not wanting to die. We are built for living, and those who help distressed individuals have a powerful force on our side.

We need to ask about how bad the pain is and how intense the desire for escape, even (especially) with individuals who have not previously expressed suicidal ideation.

There are probably other lessons from Anderson's excellent article, including understanding more about the subjective experience of someone who attempts suicide. The article is not short, but you'll be rewarded for the time spent to read it all the way through.

I came across this irreverent, but pretty informative post by the Last Psychiatrist about documentation for patients with suicidal thoughts or behavior. He is writing from the perspective of an acute services physician, but much of what he says applies across settings.

Note that the post has ads embedded in it. Besides being annoying, the ads throw off some of the formatting, so you have to scroll down to read the text.

The authors reported unexpected findings from three separate studies that compared the efficacy of a family and non-family treatment. In brief, they found that family-level outcomes measured after applying non-family treatments didn't just remain static (as they had expected), they actually declined. This relationship is correlational and does not necessarily mean that the treatments in question caused the decline, but the authors argue that the findings are striking enough to raise the question about whether unintended side effects psychosocial treatments should be subject to "safety monitoring" along the lines that biomedical products are. Something like a black box label: "Warning: This treatment manual may be hazardous to your family."

In the discussion section, Szapocznik and Prado hypothesize about the systemic mechanism for the results they found:

"The family is a system that must be viewed as composed of interdependent or interrelated members.... Family members tend to develop habitual patterns of behavior over time such that each individual in the family is accustomed to act in a certain way that in turn elicits specific predictable behaviors from others. One possible hypothesis is that if an individual is changed by an intervention that is design to change individual and not help the family adjust to these changes....the family may be negatively affected...."

Nothing in these studies relate directly to suicide. But I think there are implications for how we think about intervention, especially in light of what I've been reflecting on lately about suicide as a family issue (see posts related to family therapy)

Need for more systemic work on suicide. With respect to suicide, this article emphasized to me the need for greater conceptual clarity among systems thinkers about suicide in the context of the family system. We need to articulate in what ways suicidality might be a property of the system in which it resides, and what are the mechanisms by which family relationships might reduce the likelihood of suicide.

The complexity of defining "evidence-based practice." I've posted before (vis-à-vis the ambulatory redesign aspirations in our department) about my concerns that "evidence-based" can get too narrowly defined. What is evidence-based depends a lot on what evidence you look at, and, more to the point here, on what outcomes are measured in the studies that provide supporting evidence for an intervention. Given the documented importance of family functioning for long-term outcomes of many kinds, perhaps one of the criteria we should consider in evaluating the utility of a given treatment approach is its ability to promote family functioning.

This relates to suicide because of the ways in which I have heard distressed individuals conceptualize their presenting problem. When people seek help it is usually with a functional outcome in mind, often one that has to do with their relationships. Research studies measure symptom reduction, people care about love, work, and play. In delivering a human service, we should organize ourselves in congruence with human concerns. If we organize ourselves around "reducing depression" we run the risk that our language will become reified in our practice-the result of which could be a less connected stance toward a suicidal individual who sees his relationships, finances, or health as the primary problem, not his "symptoms." As one person I worked with paradoxically stated, "I don't care about feeling better, I just want all of these problems to go away."

Ideas around evidence-based practice are evolving. In our department, a vibrant conversation is underway. Simplistic views of what is evidence-based seem to be disappearing, as everyone realizes that "evidence-based" is a much broader and trickier term than we might like. Ultimately, I suspect that the way out of the dilemmas inherent in the term is for clinicians to collect evidence (in informal and formal ways) about change in their own cases. This kind of internal monitoring process will probably promote effectiveness more than selecting the right branded treatment, which may have aggregate data that allows it to be certified as "evidence based," but which may or may not be helping the particular individual and family we're working with.

There is a lot of material available about assessing for risk of suicide in adolescents, but much less that focuses on small children. Some cases are relatively (and I mean relatively) straightforward, like the child who says he is going to kill himself in anger when he doesn't get his way. But I have seen a fair number of young children where it is more complicated. Some of them may express the suicidality in anger, but they also take actions like grabbing a kitchen knife or putting shoelace around their necks and pulling it.

Now, in all of the cases I have seen this action has been taken in full view of parents or other adults, which makes it somewhat less concerning (at least in terms of immediate risk for suicide), but nevertheless the child has taken an action which, if done at another time and in a slightly different way could be dangerous.

Our frameworks for assessing risk in adults fall short in these cases. I know I feel on less steady ground. If anyone knows of good resources--ones that not only provide risk factors, but ways of conceptualizing suicidal behavior in young children, I'd love to hear from you.